Shu-Sen Chang

Was the economic crisis 1997-1998 responsible for rising suicide rates in East/Southeast Asia? A time-trend analysis for Japan, Hong Kong, South Korea, Taiwan, Singapore and Thailand

In 1997-1998 a widespread economic crisis hit the economies of many East/Southeast Asian countries; its impact on suicide rates across the region has not been systematically documented. We investigated the impact of the Asian economic crisis (1997-1998) on suicide in Japan, Hong Kong, South Korea, Taiwan, Singapore and Thailand. Suicide and population data for the period 1985-2006 were extracted from the World Health Organisations mortality database and Taiwanese mortality statistics. Sex-specific age-standardised suicide rates for people aged 15years or above were analysed using joinpoint regression. Trends in divorce, marriage, unemployment, gross domestic product (GDP) per capita and alcohol consumption were compared with trends in suicide rates graphically and using time-series analysis. Suicide mortality decreased in the late 1980s and early 1990s but subsequently increased markedly in all countries except Singapore, which had steadily declining suicide rates throughout the study period. Compared to 1997, male rates in 1998 rose by 39% in Japan, 44% in Hong Kong and 45% in Korea; rises in female rates were less marked. Male rates also rose in Thailand, but accurate data were incomplete. The economic crisis was associated with 10,400 more suicides in 1998 compared to 1997 in Japan, Hong Kong and Korea. Similar increases in suicide rates were not seen in Taiwan and Singapore, the two countries where the economic crisis had a smaller impact on GDP and unemployment. Time-series analyses indicated that some of the crisiss impact on male suicides was attributable to increases in unemployment. These findings suggest an association of the Asian economic crisis with a sharp increase in suicide mortality in some, but not all, East/Southeast Asian countries, and that these increases were most closely associated with rises in unemployment.

Impact of 2008 global economic crisis on suicide: time trend study in 54 countries

Objective To investigate the impact of the 2008 global economic crisis on international trends in suicide and to identify sex/age groups and countries most affected. Design Time trend analysis comparing the actual number of suicides in 2009 with the number that would be expected based on trends before the crisis (2000-07). Setting Suicide data from 54 countries; for 53 data were available in the World Health Organization mortality database and for one (the United States) data came the CDC online database. Population People aged 15 or above. Main outcome measures Suicide rate and number of excess suicides in 2009. Results There were an estimated 4884 (95% confidence interval 3907 to 5860) excess suicides in 2009 compared with the number expected based on previous trends (2000-07). The increases in suicide mainly occurred in men in the 27 European and 18 American countries; the suicide rates were 4.2% (3.4% to 5.1%) and 6.4% (5.4% to 7.5%) higher, respectively, in 2009 than expected if earlier trends had continued. For women, there was no change in European countries and the increase in the Americas was smaller than in men (2.3%). Rises in European men were highest in those aged 15-24 (11.7%), while in American countries men aged 45-64 showed the largest increase (5.2%). Rises in national suicide rates in men seemed to be associated with the magnitude of increases in unemployment, particularly in countries with low levels of unemployment before the crisis (Spearman’s rs=0.48). Conclusions After the 2008 economic crisis, rates of suicide increased in the European and American countries studied, particularly in men and in countries with higher levels of job loss.

Means restriction for suicide prevention

Limitation of access to lethal methods used for suicide--so-called means restriction--is an important population strategy for suicide prevention. Many empirical studies have shown that such means restriction is effective. Although some individuals might seek other methods, many do not; when they do, the means chosen are less lethal and are associated with fewer deaths than when more dangerous ones are available. We examine how the spread of information about suicide methods through formal and informal media potentially affects the choices that people make when attempting to kill themselves. We also discuss the challenges associated with implementation of means restriction and whether numbers of deaths by suicide are reduced.

Increase in state suicide rates in the USA during economic recession

Evidence from European countries indicates a significant rise in suicides from the economic recession, totalling more than 1000 excess deaths in the UK alone. Among the worst affected economies in Europe, such as Greece, suicides have risen by more than 60% since 2007.2 Thus far, there has been little or no analysis of US mental health data, mostly owing to delays in data availability. Here, we extend our previous analyses of recessions and suicides in Europe to assess trends in all 50 US states. We use data on suicide mortality rates from 1999 to 2010 from the Centers for Disease Control and Prevention. Unemployment data come from the Bureau of Labor Statistics. Time-trend regression models were used to assess excess suicides occurring during the economic crisis -- ie, deaths over and above the level that would be expected if historical trends continued (see appendix for methodological details). Although there are concerns that suicide data are under-reported in the USA, these biases are likely to have been consistent over this relatively short period, although they might lead to a conservative estimate of the mental health effects of the crisis. Looking across US states between 1999 and 2010, we found that the strongest correlation between unemployment and suicides was in Texas (r=0·91), but overall the correlations were statistically indistinguishable between the north, south, east, and west, or when disaggregating states by Democrat and Republican governors (appendix). Small numbers of suicides in small populations limit a state-by-state comparison for all 50 states. Similar patterns were seen if absolute numbers of suicides were used instead of overall rates. Suicide is a rare outcome of mental illness; these data are likely to be the most visible indicator of major depression and anxiety disorders, as seen in primary-care settings in Spain and in the Greek population. The pattern of accelerating suicides noted in the USA mirrors that recorded for economic reasons in Italy. Future research should explore other risk factors such as foreclosures and job and income losses, and modifying factors such as gun control policies, access to the means of self-harm, and vulnerable groups, which could explain the remaining portion of the suicide rise observed during the recession. Our findings have immediate implications for policy. Given that some countries have avoided increases in suicides despite significant economic downturns, there is a clear need to implement policy initiatives that promote the resilience of populations during the ongoing recession. Active labour market programs--projects that immediately help the unemployed find social support and new work opportunities (even part time)--and mental health prevention programs seem to mitigate significantly the negative mental health effects of recessions. The fact that countries such as Sweden have been able to prevent suicide rises despite major recessions reveals opportunities to protect Americans from further risks of suicide during the continued economic downturn. Language: en

Geography of suicide in Taiwan: Spatial patterning and socioeconomic correlates

In industrialised Western nations suicide rates tend to be high in inner city areas and socially fragmented neighbourhoods. Few studies have investigated spatial variations in suicide in non-Western settings. We estimated smoothed standardised mortality ratios (1999-2007) for suicide for each of the 358 Taiwanese districts (median population aged 15+: 27,000) and investigated their associations with area characteristics using Bayesian hierarchical models. The geographic distribution of suicide was similar in men and women; young people showed the greatest spatial variation in rates. Rates were highest in East Taiwan, a mostly mountainous rural area. There was no evidence of above average rates in large cities. Spatial patterns of method-specific suicide rates varied markedly, with solids/liquids poisonings showing the greatest geographic variation and hangings the least. Factors most strongly associated with area suicide rates were median household income, population density and lone-parent households. Spatial patterning of suicide in Taiwan differed from that observed in Western nations. Suicide prevention strategies should take into account unique local patterns.

The Evolution of the Epidemic of Charcoal-Burning Suicide in Taiwan: A Spatial and Temporal Analysis

Shu-Sen Chang and colleagues describe the epidemiology of an epidemic of suicide by charcoal burning in Taiwan and discuss possible reasons for its spread.

Economic shocks, resilience, and male suicides in the Great Recession: cross-national analysis of 20 EU countries

BACKGROUND During the 2007-11 recessions in Europe, suicide increases were concentrated in men. Substantial differences across countries and over time remain unexplained. We investigated whether increases in unaffordable housing, household indebtedness or job loss can account for these population differences, as well as potential mitigating effects of alternative forms of social protection. METHODS Multivariate statistical models were used to evaluate changes in suicide rates in 20 EU countries from 1981-2011. Models adjusted for pre-existing time trends and country-fixed effects. Interaction terms were used to evaluate modifying effects. RESULTS Changes in levels of unaffordable housing had no effect on suicide rates (P = 0.32); in contrast, male suicide increases were significantly associated with each percentage point rise in male unemployment, by 0.94% (95% CI: 0.51-1.36%), and indebtedness, by 0.54% (95% CI: 0.02-1.06%). Spending on active labour market programmes (ALMP) (-0.26%, 95% CI: -0.08 to -0.45%) and high levels of social capital (-0.048%, 95% CI: -0.0096 to -0.087) moderated the unemployment-suicide association. There was no interaction of the volume of anti-depressant prescriptions (P = 0.51), monetary benefits to unemployed persons (P = 0.77) or total social protection spending per capita (P = 0.37). Active labour market programmes and social capital were estimated to have prevented ∼ 540 and ∼ 210 male suicides, respectively, arising from unemployment in the countries studied. CONCLUSION Job losses were a critical determinant of variations in male suicide risks in Europes recessions. Greater spending on ALMP and levels of social capital appeared to mitigate suicide risks.

‘Hidden’ suicides amongst deaths certified as undetermined intent, accident by pesticide poisoning and accident by suffocation in Taiwan

ObjectiveTo identify cause-of-death categories in which suicides might be misclassified in Taiwan.MethodsWe plotted secular trends (1971–2007) in sex- and method-specific rates of deaths classified as suicide, undetermined intent and accident for the Taiwanese population aged 15+ and compared the sex, age and marital status profiles of deaths in these three categories by method of death.ResultsThe demographic profiles of registered suicides generally resembled those for deaths of undetermined intent and accidents by pesticide poisoning/suffocation but differed from those for accidents from non-pesticide poisoning/drowning/falling/poisoning by non-domestic gas. For the period 1990–2007, suicide rates based on suicides alone (14.8 per 100,000) would increase by 23, 7 and 1%, respectively, when including deaths of undetermined intent, accidental pesticide poisonings and accidental suffocations.ConclusionsSuicide rates may be underestimated by more than 30% in Taiwan because some suicides are ‘hidden’ amongst deaths certified as due to other causes.

Suicide rates among working-age adults in South Korea before and after the 2008 economic crisis

Background Multiple studies have shown that macroeconomic factors are associated with changes in suicide rates. We investigated how changes in economic conditions associated with the recent economic crisis in South Korea influenced suicide rates among working-age adults. Methods Time-series analyses were performed to examine the temporal associations of national unemployment rates and sex-employment-specific suicide rates in South Korea from 2003 to 2011, with particular attention to the increases of suicides that occurred during the recessionary period that began in 2008. We also compared the relative risk of suicide among different occupations. Results National unemployment rates were positively associated with suicide rates among employed and unemployed men and women, with a 2-month to 3 month lagged period. Significant increases of suicide rates among working-age adults during the recession were detected in most of the subgroups stratified by age, sex and employment status. Forty-three per cent of the increase of suicides was derived from the employed population. Compared with workers in elementary occupations, the relative risk of suicide for mangers increased by threefold during the recessionary period. Among those who were employed, half of the increases in suicides occurred among clerks and workers involved in sales and services. Conclusions Changes in macroeconomic conditions are tied to population-level suicide risks for employed and unemployed persons. However, these associations vary depending on sex, employment status and occupational roles. In advance of future economic crises, it is important to develop prevention initiatives intended to reach the diverse populations potentially exposed to the adverse effects of sudden economic disruptions.

Association of secular trends in unemployment with suicide in Taiwan, 1959-2007: a time-series analysis

OBJECTIVE Despite the wealth of research investigating the association of unemployment with suicide in the West, few studies have investigated the association in non-Western countries. This study aimed to investigate the relationship between secular trends in unemployment and suicide in Taiwan. STUDY DESIGN Time-series analysis. METHODS Overall and age-specific suicide rates (1959-2007) for Taiwanese men and women aged 15 years or above were calculated from national population and mortality statistics. The association of secular trends in unemployment with suicide was investigated graphically and using time-series modelling (Prais-Winsten regression). RESULTS Rises in unemployment were associated with an increase in male suicide rates, but evidence for an association in females was limited. In the model controlling for changes in gross domestic product (GDP) per capita, GDP growth, divorce and female labour force participation, for every 1% rise in unemployment, male suicide rates increased by 3.1 (95% confidence interval 1.4-4.8) per 100,000. There is no evidence for a difference in the strength of association between men of different ages. CONCLUSION Trends in suicide, particularly for adult males, appear to be influenced by unemployment. The results have implications for suicide prevention, in particular for societies facing acute rises in unemployment during recessions.